Reflections on improvisation, communication, medicine, and life

Paul Giamatti and his TV family show us how *NOT* to use 'yes and.' Thank you, paul! (screenshot: Centurylink)

Sometimes I run into the concept of "yes, and" unexpectedly, and sometimes when I do, it feels like a bump in the road. Last week, I was sitting in a meeting when an attendee raised her hand and offered a challenging opinion. The facilitator responded with "Yes, AND" — followed by a statement completely undermining the person who had just spoken. People in the room cringed.

Which led me to post on my personal facebook page* later that day:

If you say "yes, and" without embodying "yes, and," you're missing the point. And it doesn't work.

One of my insightful and talented improv friends, Tim Tracey, inquired what I meant about this statement, which was a wonderful invitation to get my brain going. What did I mean, really? Here is part of our conversation:

Tim: what do you mean by your original statement?

Me: I believe that the intention behind the concept of "yes and" is to affirm the person with whom one is interacting, and to add something new to the interaction, building upon what they have offered. So there is the principle of 'yes and' and the literal words 'yes and.' The words 'yes and' are an approximation of the intention. I have witnessed people use the words 'yes and' with a different intention, which makes the the words 'yes and' irrelevant and impotent. For example, person A says "I believe in God," and person B replies with, "Yes, and that's stupid, there is no god." In other words, it is possible to block while still uttering the words 'yes and.' The words are not enough without the intention.

Tim: Are you talking about improv or life? Actor or character?

Me: I was talking about life, but it may be true on stage, too. A: I love fishing! B: Yes, and you're lying.

Tim: i find it very difficult to yes and in life. Yes is very easy but is more difficult. But in your example, about god, that is an example of yes and. A: I believe in god. B: Yes (I affirm that you are speaking truth) AND your statement is stupid or uneducated or whatever because i know that there is no god. So I need a better example.

Me: I think that whether or not the "yes" is an affirmation depends on multiple factors, including how it's delivered, what follows it, and how it's heard by the receiver. In that example, I think that the words 'and that's stupid' undermines any affirming effect of the word 'yes.' From an actor's perspective, person B did affirm the reality that A has that opinion, but from a life perspective, B did not affirm A as a person because B negatively judged A for having that opinion. And I think that in the context of life this is relevant, because I think that the goal of improvisation in life is collaborative communication.Totally my personal opinion.

I was grateful to Tim for asking a great question about this subtle nuance of "Yes, and." While there are many people who consider "Yes and" to be the core principle of improv, if you look into the improv literature, you will find that there are plenty of people who disagree with that opinion for various reasons, including this potential disconnect between words and intention. In my workshops, participants have pointed out that you can say "Yes, and" while expressing negative sentiments, and you can say "Yes, but" while expressing supportive thoughts. Yes, both of these observations are true, AND I believe that this observation raises our awareness that the INTENTION of "Yes, and" (accept and add) is most important; the WORDS "Yes, and" are merely a convenient approximation, and must be used thoughtfully.

Here is another misuse of "Yes, and," brought to you by CenturyLink, whom I am neither endorsing or not endorsing — they just happened to make a commercial earlier this year with Paul Giamatti that uses the WORDS "Yes, and," but butchers the intention of it by turning it into a question to "pimp" someone else for the answer. That's actually the antithesis of what "Yes, and" should mean.

Paul Giamatti: Switch to CenturyLink Prism TV and get the same great channels cable gives you, without having to deal with cable.

Dad: By saying yes, and, we accept the reality created by our comedy partners, Paul.

What Dad said is ALMOST true, but saying 'yes, and' isn't enough — doing 'yes, and' is what accepts the reality created by our partners. So Dad and Mom aren't using it right. If Paul makes a statement, and Dad responds with "Yes, and ... " it should be followed with a statement by Dad that contributes to the conversation, so that Paul isn't stuck doing all the work, which is what is happening here. The fam is putting Paul on the spot, basically interrogating him and making him come up with all the answers.** The intention of "Yes, and" on stage is that each scene partner takes turns making contributions, or offers, to the scene. "And" is not a question to be flipped back at the other person; "And" prefaces a statement that moves the conversation forward.

So there you go - some reflections on the subtleties of what appears to be such a simple concept! Big thanks to Tim for asking great questions and getting this conversation going. And the next time you hear the words "Yes, and" in conversation, remember:

"When words and actions don't align, The intention of "Yes, and" can be maligned."

— Belinda

*Right now, my personal facebook page is mostly filled with stuff about my dog, food, Hamilton, and Game of Thrones.

** I think that the use of his name at the end of the last sentence is particularly condescending, also adding to the unsupportive feeling of the conversation conveyed by the actors. Also, just in case you are thinking I am a stick in the mud, I totally get that this is just a commercial trying to be funny. I swear I actually do have a sense of humor. Really! I do!

Tonight I had the lovely opportunity to pop into the University of Washington School of Medicine to lead an evening workshop for first and second year students as part of their student-run wellness series. A couple of the students had participated in one of my sessions last year at the WAFP student-resident retreat, so I felt honored that they wanted to share this work with their classmates.

After they snacked on some Pagliacci pizza, we went over some context, warmed up, and then jumped into a few exercises: the failure bow, patterns, 'yes and' conversations, and word-at-a-time proverbs. It was no surprise to me that they were smart, engaged, earnest, quick learners, and lots of fun.

What I found so distinctively inspiring wastheir remarkable creativity about the many possible applications of this work. Within minutes of introducing the core concepts, the students were coming up with unusual and highly relevant insights and questions, such as the effects of uneven use of improv strategies within a team, the use of improv communication to approach difficult conversations about race, and the mitigation of destructive manifestations of humor. Wow.

I wish I had written them all down, but I am consoled by the truth I was reminded of tonight: that medical students are the best and brightest, sincere in their efforts to make the world better in large and small ways, and that at this stage in training, they are still pluripotent, making creative connections and insightful observations, open to learning, and intrinsically innovative. I have no doubt that the next time I am lucky enough to work with medical students, they will inspire me all over again.

My experience tonight also reinforced for me the importance of the wellness aspect of improvisation in medicine. As creative as the med students are, they are already starting to show signs of reining back their participation and curbing their creativity because of a budding fear of judgment. They told me so, and I could see it. They and I both wondered: what can be done to prevent the inhibition and fear from taking hold? Before cognitive and creative paralysis set in, near-codified by a culture of fear? The students wondered aloud: If all med students learned improv, could we head off the fear at the pass, prevent it from even getting out of the gates, stop the judgment and fear before it happens?

Could improv proactively shape a cohort of med students to internalize and perpetuate a culture of resilience and support?

The principles of improv and comedy have been appearing in the business world with increasing frequency over recent years, as a highly effective and enjoyable way to generate ideas and improve teamwork. Yesterday, the New York Times published an article about Funworks, an ad agency in San Francisco whose approach to idea generation for clients is deeply integrated with the principles of improv.

Led by "talented improv and sketch artists who have years of training using the 'Yes, And' approach to building ideas," (per their website) Funworks leads intense, structured workshops to generate material for and with their advertisement clients, such as SodaStream and Clorox. As part of their strategy, they believe that creativity is directly connected to the positive working environment that they create. This belief is supported by other experts as well, including Harvard Business School professor Teresa Amabile, who says:

'When people are in a good mood ... “cognition kind of loosens up, helping us to make connections between things that are normally not associated” — the key to coming up with good ideas.'

Medicine can learn and benefit from such a mindset. Clinical practice demands quick, creative solutions to unexpected circumstances, and our innovative abilities are often stifled by tense, even acrimonious working environments. In contrast, a medical improv curriculum establishes a fun, playful atmosphere in which clinicians can feel safe, creative, and supportive of each other. Those cognitive and behavioral skills can then be taken into the workplace and put to good use. If we use medical improv training to deliberately foster positive environments and supportive relationships, then we can come up with new ideas and connections that can help us solve the challenges that we face — together.

One of the things that causes the most stress in my life is uncertainty. The inability to make plans or anticipate the future is so unsettling. The source of uncertainty can range from the mundane (will it stop raining?) to the sentimental (will she call me back?) to the serious (did I make the right choice? will he survive?), but the upshot is the same: a feeling of helplessness and stress.

Today I read an article in Time magazine, about a recent study published in Nature Communication observing the stress induced by states of uncertainty. They had a few study subjects guess whether or not there was a snake under a set of rocks; bummer thing was, if they picked the wrong rock, they would get an electric shock. (fun study!). The subjects showed more physiologic signs of stress if they weren't sure the shock was coming, and less stress if they knew it was going to happen. The author, Stephen de Berker, wrote, “Uncertainty is difficult for the brain because it makes it hard to figure out what to do [and] what decisions to make. I suspect stress—both the arousal component and the unpleasantness of it—help us deal with uncertain situations possibly by making us more alert, and also incentivizes us to avoid them.”

But maybe we don't need to avoid uncertainty (and really, we can't!). Maybe we can respond to uncertainty in a positive way. Of course we can!

A core improv skill is the ability to embrace uncertainty – or as a colleague of mine once said, it's more than embracing, it's thriving in uncertainty. As improvisers, we reshape our perspective and responses to the (neverending) state of uncertainty that is life, and learn how to live in the moment, respond in the moment, and adapt in positive ways to every change, twist, and turn. Instead of feeling thwarted by uncertainty, we blossom in it.

The author of the Nature Comm study went on to say, “I suspect that some meditative or religious practices which extoll the virtue of acknowledging only the present tense, or accepting our fate, might help reduce stress by attenuating our sensitivity to uncertainty,” he says. “Since uncertainty is about what’s going to happen in the future, if you’re completely absorbed in the present, then it seems likely that uncertainty will impact your stress less.”

Improv skills are all about staying in the present. It's that ability to attune to everything around and within us that helps us respond in the moment.

Life is intrinsically uncertain, even without rocks, snakes, and electric shocks. But rather than letting this lead to a constant state of stress, we can use our improvisation skills to thrive in uncertainty, every day.

Hello, and come on in! Every month we'll share with you a rotation of different features, contributed by your medical improv colleagues from around the world, and from the ImprovDoc team. You can look forward to reading great columns such as:

What I Taught, What I Learned - Authors share about a medical improv curriculum that they've tried: what worked, what didn't, and what they learned from the experience.

In My Life - Read stories about how improvisational communication has had an impact on someone's journey as a clinician and as a human being.

Food for Thought - A selection of articles and tidbits from academic and popular media, relevant to the conversations here at ImprovDoc.

Exercise Bank - Learn new exercises from your colleagues, with tips and tricks to go with them.

ImprovDocuments - Thoughts from the ImprovDoc Team.

Stay tuned as we roll out our ongoing blog posts over the coming year.